The Essentials of Patient Safety - Clinical Human Factors Group

The Essentials of Patient Safety
Briefing and checklisting in surgery
A number of studies have now been carried out which demonstrate the value of
checklisting and briefing which, although sometimes described separately, in practice
usually occur together. The most influential study of surgical checklists has
undoubtedly been that led by Atul Gawande as part of the World Health Organisation
(13).
The WHO surgical safety checklist ensures that the entire operating theatre
team understands the patient, the surgical procedure the equipment needed and that
evidence based interventions such as antibiotic prophylaxis or deep vein thrombosis
prophylaxis are reliably given. The 19 item checklist is completed in three stages
before induction of anaesthesia (sign in), just before skin incision (time out), and
before the patient leaves the operating theatre (sign out). Items on the checklist must
be verbally confirmed with the patient and other team members (14). The WHO Safe
Surgery Saves Lives Study Group introduced the checklist in eight countries
worldwide studying 3733 patients before and 3955 patients after the implementation
of the checklist. After implementation, deaths were reduced from 1.5% to 0.8% and
in-hospital complications by from 11% to 7.0%. In some sites the checklist prompted
the introduction of techniques that are now standard in developed countries; for
instance use of a pulse oximeter rose from 60% to over 90% in one study site over the
course of the study.
Briefings and checklists are however not a panacea. According to how they
are used, can be either a positive or negative influence on team performance. A
surgeon, for instance, can ostensibly take part in the briefing but express their
superiority and detachment by not really listening and carrying out other tasks at the
same time. A checklist can be read out by a nurse in a clipped and dismissive way
which closes down all possibility of discussion within the team.
These two interventions are important examples of how teamwork and patient
care can be improved with relatively simple measures, though persuading clinicians to
use them and actually implement them may of course be monumentally difficult.
Daily goals, pre-operative and post-operative checklists seem mundane, and this
piece of paper or even a list; it is a team intervention which, used well, can affect the
wider team functioning, the relationships across professions and hierarchies and even
the values and safety culture of the team.
These interventions just touch on some aspects of teamwork and it is
important not to think that safety just means using more checklists. The real impact of
these approaches is to bring a shared understanding, to specify team leadership in
particular situations, to anticipate problems. These wider endeavours require a more
sophisticated understanding of teamwork than we have at the moment and need to be
fostered in new types of training involving groups of healthcare professionals in novel
simulations and other environments.
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